Healthcare Provider Details

I. General information

NPI: 1316225550
Provider Name (Legal Business Name): SUSAN TILLMAN ELLIOTT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 MASSACHUSETTS AVE.,NW SUITE 308
WASHINGTON DC
20016-4382
US

IV. Provider business mailing address

4910 MASSACHUSETTS AVE.,NW SUITE 308
WASHINGTON DC
20016-4382
US

V. Phone/Fax

Practice location:
  • Phone: 202-695-1000
  • Fax: 202-503-1791
Mailing address:
  • Phone: 202-695-1000
  • Fax: 202-503-1791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number18955
License Number StateDC

VIII. Authorized Official

Name: DR. SUSAN TILLMAN ELLIOTT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 202-695-1000